The decisions that changed this physician’s career


I knew the moment when my career in pediatrics was over.  I was in the fourth year of my med-peds residency, taking overnight call in the pediatric ICU.  Nights were busy, stressful and I was alone.  A young boy came in as an unrestrained MVA after his father hit another car. Dad was OK (although severely distraught), but the five-year-old towhead boy in front of me was not, with his head immobilized in a C collar and a breathing tube down his throat.

His brain had swelling from a shearing injury that resulted from the decelerating forces applied to his neurons on impact.  He wasn’t in a coma, but definitely not alert or able to listen and follow commands. But awake enough to be thrashing about from the discomfort of the breathing tube and his immobilized head and the IV’s in his arms and the catheter in his bladder.

Mom and Dad watched helplessly at his bedside. Standard of care for someone on a ventilator with these tubes is to receive medication for pain and anxiety.  The neurosurgeons were adamant against this as it would cloud their ability to assess changes that could signify more swelling of his brain. If we gave those medicines, they would need to do a surgical procedure to put a bolt or pressure monitor through his skull, to continuously measure for potential increases in swelling and pressure.

Standing a few feet away, I watched those parents.  The dad was a wreck, wracked with guilt, fear, and anguish. Mom was fighting back tears, avoiding eye contact with her husband while grasping her son’s hand.   I stared at the boy, with the same blond hair as my own 4-year-old son, wrestling with my own emotional distress over the situation. And I wrote an order in the chart to give him a small dose of morphine.  And with that decision my future as a pediatric critical care physician ended before it even started.

You see, that order to give that young boy morphine was the absolute worst decision an MD could have made.  I acted at the moment as a parent, not a doctor. I wanted to relieve the pain/suffering for the boy and his mom and dad. But the dose I gave was not enough to make him comfortable. But it might have been enough to cloud our ability to detect subtle neurologic changes. And with my decision, I neither helped the boy nor his parents. But I did put him at increased risk of delay in diagnosing further brain swelling.  I acted with my heart, not my head.

It’s been almost 16 years since that night. I decided to focus and train in adult critical care.  Critical care does not always mean comfortable care. By its very nature, many interventions are uncomfortable and often downright painful. But in these critically ill patients, medications such as morphine and Ativan can make low blood pressure worse, alter mental status, and lead to respiratory failure. It is by no means black and white; one or the other … and finding that balance for individual patients is an ongoing battle and challenge in the ICU.

I passed on training in pediatric critical care. It was too difficult for me to have an appropriate emotional distance.  Although not easy, it has been easier for me deliver this critical care to adults; children being just too innocent and frankly feels too close to home.  Over the past 16 years, I have come up with my own coping strategies for dealing with the stress of these situations.  Many physicians approach patients and their families with a cool, clinical, but detached demeanor.  Others find solace in alcohol or other mind-numbing substances.  My approach has not been to shy away from engaging patients and their families. I have not avoided difficult discussions whether it be a new diagnosis of lung cancer or an end of life discussion with someone dying on a respirator. But I have tried to compartmentalize the stress of the ICU, leaving it behind as I use my thirty-minute commute to transition back home to my family.

So again, here lies the challenge. How can I be the doctor I want to be? Engaged with my patients, but not too emotionally invested.  Thoughtful about my approach to the invasive nature of interventions yet mindful of its potential to cause pain and suffering.  And how to still save part of myself for when I get home to participate in my family’s life in meaningful ways.

This is where training for triathlons helps bridge my two worlds.  There is something about the rhythmic crush of gravel during a run under my feet, or the weightlessness of my body as my arms cut through the water, or the air going in and out of my chest while watching the pavement glide under the front wheel of my bike to help me wrestle with my demons. I may not have shed a tear over the 25-year-old newlywed who died this past week in my ICU.

But he was on my mind during my runs, and I have been able to get some closure on the role I played with him and his family during the last few days of his life. And my ability to think, distraction free, during a bike workout led to a new approach and a productive talk with my son that resulted in the best conversation I had with him in a long time.  Now I don’t mean to suggest that after every five-hour bike ride I come into the house all refreshed and ready to engage my family with boundless energy, leaving all my worries behind. But If I am going to try and find some way to sustain a career in critical care medicine as well as navigate the challenges two teenagers pose at home, iron distance training might not be enough. Ultra-running anyone?

Jeremy Topin is a critical care physician who blogs at Balance.

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